Acrochordon: Pathophysiology

00:01 Welcome. With this talk we're going to look at another not so interesting but nevertheless important benign lesion of the skin.

00:10 It goes by the fancy name of an acro chordon.

00:13 In fact what we're talking about here is a very non fancy thing called a skin tag.

00:18 So acrochordon s are skin tags or wens or papillomas or even more fancy fibroepithelial polyps, are benign outgrowths of normal skin, so pretty common and not all that fancy. The epidemiology is that yes, as I've already said, they're common in adults.

00:40 We see increasing numbers with age.

00:43 It's actually more common in obese patients than those with diabetes.

00:46 That may be in part because of elevated levels of insulin and insulin resistance, states that are driving fibroblasts, dermal fibroblast proliferation plus or minus some proliferation of the overlying epithelium. There's an increased frequency during the second trimester of pregnancy, often regressing after the birth of the baby, and that may obviously be related to hormonal Anal stimulation, and there are skin tags, typically around the anus, that are associated with Crohn's disease and that may be related to the cytokine environment that happens in with the Th1 type CD4 driven inflammation in Crohn's.

01:26 The pathophysiology. So it's a combination of friction and any trauma to the skin kind of rubbing of it will induce some degree of proliferation.

01:39 So there may be local irritation of the skin.

01:42 There are hormonal influences clearly such as insulin or estrogens.

01:46 You get proliferation of skin cells.

01:48 That's both epithelium and the underlying dermal fibroblasts.

01:52 And voila an acrochordon arises.

01:55 Now there are some syndromic states where there is a loss of function mutation in a tumor suppressor.

02:03 And that's the Folliculin gene happens pretty infrequently.

02:07 But patients who have multiple multiple acrochordon s may have this mutation. It's part of the Birt-hogg-dubé syndrome.

02:16 Probably don't need to remember that Clinical presentation overall. Well, these are, as we've already talked about, small, soft, flesh colored for the most part, maybe slightly pigmented pedunculated lesions that kind of hang off like a skin tag from the normal level of the skin.

02:36 They can become itchy and irritated, or particularly if you play with them or rub them, and they can catch on jewelry or clothing when traumatized.

02:46 If they become infarcted, so again, if you've torsed them or in some way cut off the blood supply to these, then they can be appear kind of red or black. Common locations are kind of an intertriginous areas axilla and inguinal region, the neck is common, below the breasts in the inframammary region.

03:08 And as I said in patients with Crohn's disease, you may have perianal skin tags.

03:14 So how are we going to make the diagnosis? A lot of this is on physical exam recognizing it for what it is.

03:21 You see that skin polyp kind of sticking up over the surface of the flat surface of the skin. But there is a differential diagnosis, and actually excising it and looking under the microscope may help you to sort out other entities that may be in action. So what is being shown here is a fibroepithelial polyp.

03:40 A when a, you know, a typical acrochordon and it looks pretty benign, it looks like kind of normal skin.

03:48 There's a slightly thickened epithelial layer, but the keratin is not particularly pronounced in the stratum corneum.

03:55 The dermis is maybe a little bit expanded, a little bit more fibrotic, but there's really not much there.

04:01 And that's kind of what you want to see in a typical acrochordon.

04:05 On the other hand, in the differential neurofibromas can appear like these pedunculated polyps.

04:13 They tend to be larger. They tend to be firmer, they tend to have a neural core.

04:17 And so excising them and looking under the microscope to rule that out as a potential syndrome is important.

04:24 And you can also have pedunculated dermal nevi.

04:27 Now they're a dermal nevus, pedunculated or otherwise.

04:31 And an acrochordon are both benign lesions.

04:34 But it might be important interesting in some cases to distinguish whether you're looking at one or the other, so histology will help.

04:41 If this were a pedunculated dermal nevus, we would see many more melanocytes and we would see melanocytes deep within the dermis structure. So again, not much to look at. It looks remarkably banal and benign.

05:00 How do you manage this.

05:01 Well snip excision literally there's very little bleeding that's associated with it. You can cauterize that.

05:09 Cryosurgery works. Electrodesiccation I have relatives who have a significant number of these, and they just tie little strings around them and infarct them, which works quite well after a couple of days.

05:23 So many, many ways to treat them.

05:25 They are totally benign.

05:27 And you, unless you have the folliculin mutation, not really anything that you should even be thinking too seriously about.

05:36 So with that, we we have covered the topic of acrochordon wens, epithelial fibroepithelial, polyps, etc..